Carol Rees Parrish, R.D., M.S., Series Editor Pre-op NPO And .
NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #90 Carol Rees Parrish, R.D., M.S., Series Editor Pre-op NPO and Traditional Post-op Diet Advancement: Time to Move On Kate Willcutts The standard method for initiating and advancing oral diet after surgery is evolving. The old approach includes nasogastric decompression and withholding oral diet until bowel function has clearly returned. While the use of nasogastric tubes (NGT) for decompression after surgery is not as common, the initiation of oral diet is still often held until the perceived return of bowel function. The resumption of an oral diet in this setting may begin with ice chips or sips of clear liquids, and then advance to clear liquids, then gradually to a regular diet. There is substantial evidence that this traditional approach is unnecessary in most instances. This paper will review that evidence as well as address the role of nutrition in the Enhanced Recovery After Surgery (ERAS) pathways. POSTOPERATIVE ILEUS ostoperative ileus (POI) is defined as “transient cessation of coordinated bowel motility after surgical intervention, which prevents effective transit of intestinal contents or tolerance of oral intake” (1). A “primary” POI occurs without being caused by postoperative complications. A “secondary” POI occurs due to a postoperative complication such as infection, anasto- P Kate Willcutts, MS, RD, CNSD, Nutrition Support Specialist, University of Virginia Health System, Digestive Health Center of Excellence, Charlottesville, VA. 16 PRACTICAL GASTROENTEROLOGY DECEMBER 2010 motic leak, obstruction, etc. (2). Prolonged POI reduces patient satisfaction, delays hospital discharge, and increases the cost of hospital care (3,4). A POI is considered prolonged if it lasts 5 days (5). Earlier data demonstrated that after surgery small bowel motility typically returns in 1 day, gastric motility in 1–2 days and colonic motility in 3–5 days (6). The types of surgery that are most likely to cause POI include major surgeries in the abdomen and pelvis (5) particularly bowel resections (5) and colon surgery (7). However, other types of procedures have also been (continued on page 20)
Pre-op NPO and Traditional Post-op Diet Advancement NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #90 (continued from page 16) documented to cause POI. Those include: cardiac surgery, orthopedic surgery and trauma (2). The pathogenesis of POI is believed to be multifactorial. There appear to be four different pathways initiated by surgical stress that lead to POI: neurogenic (activation of inhibitory reflexes), hormonal, and inflammatory responses, and pharmacological causes (endogenous and analgesic opioids) (2). The incidence of POI has been reduced over the years with improvements in surgical techniques and anesthesia (8). In fact, there are some who question whether primary POI exists (8). NASOGASTRIC DECOMPRESSION Historically, surgeons have waited until gut function returns before removing the decompressing NGT and allowing oral or enteral feeding; this is particularly true after abdominal or pelvic surgeries due to fear of complications caused by increased bowel contents. These complications include aspiration and subsequent pneumonia, wound dehiscence, anastomotic breakdown and subsequent fistula formation (9). They also believed that NGT decompression reduced POI, nausea and vomiting. The tradition of leaving in a NGT after surgery until the POI resolved was initially questioned in the published literature in the early 1980’s. Multiple studies since then have shown that postoperative use of NGT for decompression does not reduce postoperative nausea and vomiting (PONV) (10,11), or reduce anastomotic or other complications (11,12). In fact, discontinuing the use of NGTs in the post-op period has been shown to shorten POI and reduce fever, atelectasis and pneumonia (13). Avoidance of NGTs is one component of the Enhanced Recovery After Surgery (ERAS) protocols that will be discussed later in this article. A recently published survey showed 76% of responding U.S. surgeons (n 407) removed the NGT on POD 0 or did not use one at all (5). Selective use of the NGT is the current recommendation. MARKERS OF BOWEL FUNCTION Part of the confusion associated with studying the topic of postoperative nutrition is the lack of a clear 20 PRACTICAL GASTROENTEROLOGY DECEMBER 2010 marker designating the return of bowel function. Studies have shown that lack of bowel sounds (BS), passage of flatus or stool are not diagnostic for an ileus (14–18). BS are an unreliable marker of normal bowel function for several reasons. Prior to resumption of coordinated motility after surgery there are random electrical impulses followed by random muscle contractions (19). In this situation, BS can indicate antegrade movement of bowel contents (20). Furthermore, BS may or may not be present with normal bowel activity (21). Waiting for first flatus or stool is not a timely measure of the initial return of bowel function. Early postoperative feeding studies have demonstrated that feeding can safely begin prior to the return of flatus or stool (22–26). Feeding may actually be helpful in reducing POI by stimulating bowel motility. Of note, the time frames for the return of bowel function after surgery are based on return of bowel function without feeding. Studies have shown quicker return of bowel function with feeding (27–29). Kasparek studied colonic motility after early food status post colorectal surgery (29). They found that feeding a high fat (53% of kcals) meal of 500 kcals total on postoperative day (POD) 1 resulted in increased colonic motility when compared to standard treatment of nil per os (NPO). Unfortunately, a high percentage (66%) of the patients experienced nausea after this meal. The authors questioned whether a lower fat meal would produce a similar return of colonic function without causing nausea. LAPAROSCOPIC SURGERY There is little evidence to support the practice of leaving an NGT in after surgery and waiting for the traditional markers of bowel function return prior to starting an oral diet. In fact, when technology advanced to the point that laparoscopic surgeries could be performed, surgeons no longer applied the same rules regarding postoperative feeding. Patients’ diets were advanced quickly due to the surgeons’ theory that this less invasive procedure that involved less bowel manipulation and anesthesia would naturally not cause a POI or if so, it would naturally be shorter (18). Since then it has been demonstrated that laparoscopic
Pre-op NPO and Traditional Post-op Diet Advancement NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #90 surgery results in a 30% reduction in length of POI and hospital stay (30). Two separate studies (18,31) evaluated laparoscopic vs. open procedures in colorectal surgery patients. In both studies, the laparoscopic group tolerated earlier oral diet and had a shorter hospital length of stay (LOS). EARLY RECOVERY AFTER SURGERY PATHWAYS Early feeding after surgery is a component of the pathways that have been used to enhance overall recovery after surgery. The Early Recovery After Surgery (ERAS) pathway or modifications of it include up to 20 perioperative interventions (32). Most of the pathways that have been published involve lower gastrointestinal (GI) surgery patients. The interventions typically include: extensive preoperative counseling, no bowel preparation, antibiotic prophylaxis, limited preoperative fasting, etc. (see Table 1). Use of such pathways has led to earlier return of GI function and shorter hospital LOS by 1–4 days (33). The enhanced recovery pathways originated in Europe. A survey done in the U.S. by Delaney and colleagues (5) showed 30% of the surgeons who responded worked in hospitals that had a perioperative protocol for patients undergoing bowel resections. Hospitals with electronic medical records (EMR) more often used care pathways than those without EMRs. The interventions that were most common to the pathways used in the U.S. were: early ambulation, early diet progression, opioid-sparing techniques and early removal of NGT or no NGT at all (5). Overall use of a standard pathway like the ERAS is still rare in the U.S. PREOPERATIVE FASTING AND PREOPERATIVE CARBOHYDRATE LOADING One component of the ERAS-type pathways addresses preoperative fasting and carbohydrate loading. Despite the lack of evidence to support the practice of preoperative fasting, many U.S. hospitals begin a preoperative fast at midnight before the surgery (31). The current evidence supports changing the practice by shortening the length of fasting time. The ERAS-type pathways address this change in preoperative fasting as well as carbohydrate loading. Table 1. Suggested Summary Guidelines: From Evidence to Bedside Extensive preoperative counseling No bowel preparation Antibiotic prophylaxis Limited preoperative fasting: solids allowed until six hrs prior to surgery and clear liquids up until two hrs before surgery Thoracic epidural Selective use of NGT or early removal of NGT Avoidance of perioperative fluid overload Early (POD 0 or 1) feeding and oral supplements 200 mL 2–3 times/day from the day of surgery until “normal food intake achieved” Continue supplementation (nutrition support) if the patient was malnourished baseline and early mobilization Consider gum chewing for 30 minutes TID on POD 1 Early ambulation Opioid-sparing techniques A Cochrane review published in 2003 that included 22 randomized controlled trials (RCT) concluded that changing the preoperative fasting to clear liquids until 2 hrs prior to surgery does not increase risk of complications (34). In fact, guidelines from Scandinavian and American Anesthesiology groups now recommend clear liquids until 2 hrs and solid foods until 6 hrs prior to starting anesthesia (35,36). The benefits of this practice include reduced preoperative hunger, thirst, and anxiety (34) and improved insulin sensitivity postoperatively (37). Furthermore, 2 randomized controlled trials show shorter LOS and faster recovery in colorectal surgery patients who receive preoperative carbohydrates such as: a hypo-osmolar maltodextrin drink 800 mL the night before surgery and 400 mL three hours prior to surgery (38,39). LARGE BOWEL SURGERY The majority of early oral feeding studies have been done in patients undergoing elective colorectal surgery PRACTICAL GASTROENTEROLOGY DECEMBER 2010 21
Pre-op NPO and Traditional Post-op Diet Advancement NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #90 (16,23,26,40,41). Each study has different methods in terms of how they introduce oral feedings in their study and control groups. However, they have all shown that compared to the control group, the early oral feeding groups have no more complications, and in some, the early fed group had shorter hospital LOS (14–16,40,42,43). SMALL AND LARGE BOWEL SURGERY While most studies have investigated lower bowel surgery or gynecologic surgery, several studies have combined patients undergoing both upper and lower bowel surgery. Binderow and colleagues randomized 64 patients who had undergone open colon or ileal resection to regular diet on POD 1 vs. waiting for stool prior to starting an oral diet (18). They found no differences in the need for replacement of NGT due to nausea and vomiting or in the length of the POI. Behrns and colleagues randomized 44 patients undergoing surgery on their small bowel (35%), colon (53%) or both (12%), to standard treatment of clear liquids after stool or flatus vs. starting clear liquids on POD 2 (14). The control group was maintained on clear liquids until they tolerated 750 mL/day at which point they were advanced to a solid diet and then discharged after tolerating 3 meals. The protocol for the study group was to receive clear liquids on POD 2, regardless of whether they had experienced flatus or had a bowel movement, and they were to be discharged on clear liquids on POD 4 if there were no complications. Their diet was advanced at home based on information gathered during post discharge phone calls by a clinician on the research team. There was a trend towards reduced LOS in the study group (average of 4 vs 6 days). Due to the small sample size this was not statistically significant (14). UPPER GASTROINTESTINAL SURGERIES While there is strong evidence suggesting that it is safe to feed soon after lower GI surgery, there is limited evidence that this practice is safe in upper GI surgery patients. Surgeons are hesitant to allow early feeding in this patient population due to the concern of the effect of eating on gastric distention and potential 22 PRACTICAL GASTROENTEROLOGY DECEMBER 2010 anastomotic leaks (27). One study in 447 patients who had undergone one of the following: hepatic, pancreatic, gastric (total and subtotal resections), esophageal, pancreatoduodenectomy and other miscellaneous upper GI surgeries were randomized to oral diet at will on POD 1 vs. jejunostomy feeding POD 1 and allowing oral diet on POD 6 (27). The orally fed group had a significantly shorter time to flatus after surgery, had fewer post-discharge complications, and had no more major complications. In a smaller study, 35 patients who underwent gastric resection were randomized to 2 different diet progressions: Early – sips of clears on POD 1, clear liquids on POD 2 and soft diet on POD 3 vs. Late sips of clears on POD 3, clear liquids on POD 4–5 and soft diet on POD 6 (28). The earlier fed group had significantly faster return to bowel function and shorter LOS. OTHER TYPES OF SURGERIES Although most of the studies cited thus far have involved patients undergoing GI surgery, there are multiple studies with similar results in gynecologic surgery patients. A summary of the gynecologic studies published by Cochrane reviews states that early feeding is safe and associated with shorter hospital LOS (44). However, there is increased nausea in the early fed patients (44). There are also a few studies in cardiac (45), urology (46), and otolaryngology surgery patients (17) that show early feeding is safe. EXCLUSION CRITERIA Not all patients may be candidates for early oral diet after surgery. Each of the studies reviewed above excluded certain categories of patients. The most common exclusion criteria were: patients who underwent emergent surgeries or combined surgeries. Others included: history of prior intestinal resection, projected prolonged hospital stay, perforation or abscess with associated sepsis, life expectancy 3 months, short gut or other reason for requiring parenteral nutrition. Until these types of patients are included in early postoperative feeding studies, the safety of early postoperative (continued on page 24)
Pre-op NPO and Traditional Post-op Diet Advancement NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #90 (continued from page 22) Six randomized trials and three meta-analyses have been published evaluating the practice of gum chewing after surgery to reduce POI (47–49,50–55). The theory is that gum chewing acts as sham feeding and as such stimulates the cephalic phase of digestion thereby increasing secretions from the salivary glands, stomach and biliopancreatic systems as well as increasing GI motility. In trials of elective colorectal surgery patients, comparing standard treatment to gum chewing 3 times per day for 5–60 minutes POD1, the length of the POI was significantly shorter as demonstrated by less time to the first flatus, first stool and shorter LOS (47). bowel function” (as determined by the primary surgeon) prior to starting the diet. Different approaches have been used to study the ideal postoperative diet. Kawamura and colleagues used appetite as a guide (58). They allowed water, tea, and isotonic drink immediately after NGT removal in patients after open and laparoscopic colon surgeries. Patients were then fed based on their appetite and preferences. By POD 1, 27% were eating and tolerating solid foods. By POD 2, the number had risen to 81.3% and by POD 3, 97.1% were tolerating solid foods (58). Postoperative food preferences were studied in 145 patients who were allowed to eat within 24 hours after colorectal surgery (59). POD 1, the most commonly preferred foods and beverages included: toast (80%), fruit juice (75%); broth (73%); fresh fruit (73%); potatoes (73%); egg (70%); coffee/tea (64%); ice cream (64%); crackers (64%); pudding, yogurt and sandwiches (61%). Most of these foods are not part of a clear or full liquid diet. On POD 2 similar foods and beverages as well as cooked vegetables; hot cereal; and casseroles were chosen. Tolerance to these foods and beverages was not evaluated in this study. MEDICATIONS CONCLUSION Various medications have been studied to evaluate their effectiveness in reducing POI. Unfortunately none of the prokinetic medications have been effective (32). Use of laxatives for this purpose requires more study (56). Avoiding opioids such as morphine is recommended due to their known inhibitory effect on bowel motility. A relatively new medication, alvimopan, a mu-opioid receptor antagonist that blocks the inhibitory effects of opioids on bowel activity, was approved in 2008 by the Food & Drug Administration for use in postoperative ileus. It has been shown to reduce the POI up to 28 hrs (2). Based on the most current evidence a postoperative diet can be safely started prior to traditional markers of the return of bowel function in most patients and that the ideal postoperative diet is a patient self select diet. It is important to note that most studies evaluating earlier oral diet postoperatively excluded patients undergoing emergent surgery. With regard to withholding feeding prior to surgery, better outcomes may be achieved by allowing oral diet with solid foods until six hours prior to anesthesia and carbohydrate containing clear liquids until two hours prior to anesthesia. n oral feeding for these patients cannot be presumed. Furthermore, private communications with colorectal surgeons indicates the heightened concern for aspiration pneumonia in the elderly and those with questionable mental status as their rationale for a more cautious approach in initiating and advancing oral diet after surgery in those patient groups. GUM CHEWING References POSTOPERATIVE DIET There is a lack of evidence for the use of clear liquid diets after surgery. Jeffery and colleagues randomized patients to a clear liquid or regular diet after open abdominal surgery and found no difference in nausea and vomiting (57). Of note, they did wait for “return of 24 PRACTICAL GASTROENTEROLOGY DECEMBER 2010 1. Delaney CP, Kehlet H, Sengaore AJ, et al. Clinical Consensus Update in General Surgery: Postoperative ileus: profiles, risk factors, and definitions- a framework for optimizing surgical outcomes in patients undergoing major abdominal and colorectal surgery. 2006; http://www.clinicalwebcasts.com. Accessed August 9, 2010, 2010. 2. Augestad KM, Delaney CP. Postoperative ileus: impact of pharmacological treatment, laparoscopic surgery and enhanced recov- (continued on page 26)
Pre-op NPO and Traditional Post-op Diet Advancement NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #90 (continued from page 24) 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 26 ery pathways. World J Gastroenterol. May 7 2010;16(17): 2067-2074. Goldstein JL MK, Delaney CP et al. Inpatient economic burden of postoperative ileus associated with abdominal surgery in the United States. Pharmacy and Therapeutics. 2007;32:82-90. Asgeirsson T, El-Badawi KI, Mahmood A, et al. Postoperative ileus: it costs more than you expect. J Am Coll Surg. Feb 2010;210(2):228-231. Delaney CP, Senagore AJ, Gerkin TM, et al. Association of surgical care practices with length of stay and use of clinical protocols after elective bowel resection: results of a national survey. Am J Surg. Mar 2010;199(3):299-304; discussion 304. Wilson JP. Postoperative motility of the large intestine in man. Gut. Sep 1975;16(9):689-692. Holte K, Kehlet H. Postoperative ileus: a preventable event. Br J Surg. Nov 2000;87(11):1480-1493. Morris IR. Does postoperative ileus exist? J Crit Care. Dec 2009;24(4):614-616. Sands DR, Wexner SD. Nasogastric tubes and dietary advancement after laparoscopic and open colorectal surgery. Nutrition. May 1999;15(5):347-350. Kerger KH, Mascha E, Steinbrecher B, et al. Routine use of nasogastric tubes does not reduce postoperative nausea and vomiting. Anesth Analg. Sep 2009;109(3):768-773. Cheatham ML, Chapman WC, Key SP, et al. A meta-analysis of selective versus routine nasogastric decompression after elective laparotomy. Ann Surg. May 1995;221(5):469-476; discussion 476-468. Cunningham J, Temple WJ, Langevin JM, et al. A prospective randomized trial of routine postoperative nasogastric decompression in patients with bowel anastomosis. Can J Surg. Dec 1992;35(6):629-632. Nelson R, Tse B, Edwards S. Systematic review of prophylactic nasogastric decompression after abdominal operations. Br J Surg. Jun 2005;92(6):673-680. Behrns KE, Kircher AP, Galanko JA, et al. Prospective randomized trial of early initiation and hospital discharge on a liquid diet following elective intestinal surgery. J Gastrointest Surg. MarApr 2000;4(2):217-221. Bufo AJ, Feldman S, Daniels GA, et al. Early postoperative feeding. Dis Colon Rectum. Dec 1994;37(12):1260-1265. Feo CV, Romanini B, Sortini D, et al. Early oral feeding after colorectal resection: a randomized controlled study. ANZ J Surg. May 2004;74(5):298-301. Seven H, Calis AB, Turgut S. A randomized controlled trial of early oral feeding in laryngectomized patients. Laryngoscope. Jun 2003;113(6):1076-1079. Binderow SR, Cohen SM, Wexner SD, et al. Must early postoperative oral intake be limited to laparoscopy? Dis Colon Rectum. Jun 1994;37(6):584-589. Livingston EH, Passaro EP, Jr. Postoperative ileus. Dig Dis Sci. Jan 1990;35(1):121-132. Toumadre JP, Barclay M, Fraser R, et al. Small intestinal motor patterns in critically ill patients after major abdominal surgery. Am J Gastroenterol. Aug 2001;96(8):2418-2426. Schulman AS, Sawyer RS. Have you passed gas yet? Time for a new approach to feeding patients postoperatively. Practical Gastroenterology. 2005;32:82-88. Pearl ML, Frandina M, Mahler L, et al. A randomized controlled trial of a regular diet as the first meal in gynecologic oncology patients undergoing intraabdominal surgery. Obstet Gynecol. Aug 2002;100(2):230-234. Reissman P, Teoh TA, Cohen SM, et al. Is early oral feeding safe after elective colorectal surgery? A prospective randomized trial. Ann Surg. Jul 1995;222(1):73-77. PRACTICAL GASTROENTEROLOGY DECEMBER 2010 24. Minig L, Biffi R, Zanagnolo V, et al. Reduction of postoperative complication rate with the use of early oral feeding in gynecologic oncologic patients undergoing a major surgery: a randomized controlled trial. Ann Surg Oncol. Nov 2009;16(11): 3101-3110. 25. Schilder JM, Hurteau JA, Look KY, et al. A prospective controlled trial of early postoperative oral intake following major abdominal gynecologic surgery. Gynecol Oncol. Dec 1997;67(3):235-240. 26. Han-Geurts IJ, Jeekel J, Tilanus HW, et al. Randomized clinical trial of patient-controlled versus fixed regimen feeding after elective abdominal surgery. Br J Surg. Dec 2001;88(12):1578-1582. 27. Lassen K, Kjaeve J, Fetveit T, et al. Allowing normal food at will after major upper gastrointestinal surgery does not increase morbidity: a randomized multicenter trial. Ann Surg. May 2008;247(5):721-729. 28. Hur H, Si Y, Kang WK, Kim W, et al. Effects of early oral feeding on surgical outcomes and recovery after curative surgery for gastric cancer: pilot study results. World J Surg. Jul 2009;33(7): 1454-1458. 29. Kasparek MS, Mueller MH, Glatzle J, et al. Postoperative colonic motility increases after early food intake in patients undergoing colorectal surgery. Surgery. Nov 2004;136(5):1019-1027. 30. Gervaz P, Inan I, Perneger T, et al. A prospective, randomized, single-blind comparison of laparoscopic versus open sigmoid colectomy for diverticulitis. Ann Surg. Jul 2010;252(1):3-8. 31. Liberman MA, Phillips EH, Carroll BJ, et al. Laparoscopic colectomy vs traditional colectomy for diverticulitis. Outcome and costs. Surg Endosc. Jan 1996;10(1):15-18. 32. Lassen K, Soop M, Nygren J, et al. Consensus review of optimal perioperative care in colorectal surgery: Enhanced Recovery After Surgery (ERAS) Group recommendations. Arch Surg. Oct 2009;144(10):961-969. 33. Walter CJ, Collin J, Dumville JC, et al. Enhanced recovery in colorectal resections: a systematic review and meta-analysis. Colorectal Dis. May 2009;11(4):344-353. 34. Brady M, Kinn S, Stuart P. Preoperative fasting for adults to prevent perioperative complications. Cochrane Database Syst Rev. 2003(4):CD004423. 35. Soreide E, Eriksson LI, Hirlekar G, et al. Pre-operative fasting guidelines: an update. Acta Anaesthesiol Scand. Sep 2005;49(8): 1041-1047. 36. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: a report by the American Society of Anesthesiologist Task Force on Preoperative Fasting. Anesthesiology. Mar 1999;90(3):896905. 37. Nygren J. The metabolic effects of fasting and surgery. Best Pract Res Clin Anaesthesiol. Sep 2006;20(3):429-438. 38. Noblett SE, Watson DS, Huong H, et al. Pre-operative oral carbohydrate loading in colorectal surgery: a randomized controlled trial. Colorectal Dis. Sep 2006;8(7):563-569. 39. Nygren J, Thorell A, Ljungqvist O. Preoperative oral carbohydrate nutrition: an update. Curr Opin Clin Nutr Metab Care. Jul 2001;4(4):255-259. 40. DiFronzo LA, Yamin N, Patel K, et al. Benefits of early feeding and early hospital discharge in elderly patients undergoing open colon resection. J Am Coll Surg. Nov 2003;197(5):747-752. 41. Hartsell PA, Frazee RC, Harrison JB, et al. Early postoperative feeding after elective colorectal surgery. Arch Surg. May 1997;132(5):518-520; discussion 520-511. 42. Petrelli NJ, Cheng C, Driscoll D, et al. Early postoperative oral feeding after colectomy: an analysis of factors that may predict failure. Ann Surg Oncol. Dec 2001;8(10):796-800. 43. Lewis SJ, Egger M, Sylvester PA, et al. Early enteral feeding versus “nil by mouth” after gastrointestinal surgery: systematic
Pre-op NPO and Traditional Post-op Diet Advancement NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #90 44. 45. 46. 47. 48. 49. 50. review and meta-analysis of controlled trials. BMJ. Oct 6 2001;323(7316):773-776. Charoenkwan K, Phillipson G, Vutyavanich T. Early versus delayed (traditional) oral fluids and food for reducing complications after major abdominal gynaecologic surgery. Cochrane Database Syst Rev. 2007(4):CD004508. Miedema BW, Schillie S, Simmons JW, et al. Small bowel motility and transit after aortic surgery. J Vasc Surg. Jul 2002;36(1):19-24. Pruthi RS, Chun J, Richman M. Reducing time to oral diet and hospital discharge in patients undergoing radical cystectomy using a perioperative care plan. Urology. Oct 2003;62(4):661665; discussion 665-666. Vasquez W, Hernandez AV, Garcia-Sabrido JL. Is gum chewing useful for ileus after elective colorectal surgery? A systematic review and meta-analysis of randomized clinical trials. J Gastrointest Surg. Apr 2009;13(4):649-656. Noble EJ, Harris R, Hosie KB, et al. Gum chewing reduces postoperative ileus? A systematic review and meta-analysis. Int J Surg. Apr 2009;7(2):100-105. de Castro SM, van den Esschert JW, van Heek NT, et al. A systematic review of the efficacy of gum chewing for the amelioration of postoperative ileus. Dig Surg. 2008;25(1):39-45. Kouba EJ, Wallen EM, Pruthi RS. Gum chewing stimulates bowel motility in patients undergoing radical cystectomy with urinary diversion. Urology. Dec 2007;70(6):1053-1056. 51. Asao T, Kuwano H, Nakamura J, et al. Gum chewing enhances early recovery from postoperative ileus after laparoscopic colectomy. J Am Coll Surg. Jul 2002;195(1):30-32. 52. Matros E, Rocha F, Zinner M, et al. Does gum chewing ameliorate postoperative ileus? Results of a prospective, randomized, placebo-controlled trial. J Am Coll Surg. May 2006;202(5):773778. 53. Schuster R, Grewal N, Greaney GC, et al. Gum chewing reduces ileus after elective open sigmoid colectomy. Arch Surg. Feb 2006;141(2):174-176. 54. Quah HM, Samad A, Neathey AJ, et al. Does gum chewing reduce postoperative ileus following open colectomy for leftsided colon and rectal cancer? A prospective randomized controlled trial. Colorectal Dis. Jan 2006;8(1):64-70. 55. Niloff PH. Does gum chewing ameliorate postoperative ileus? Results of a prospective randomized, placebo-controlled trial. J Am Coll Surg. Sep 2006;203(3):405. 56. Kehlet H. Postoperative ileus—an update on preventive techniques. Nat Clin Pract Gastroenterol Hepatol. Oct 2008;5(10): 552-558. 57. Jeffery KM, Harkins B, Cresci GA, et al. The clear liquid diet is no longer a necessity in the routine postoperative management of surgical patients. Am Surg. Mar 1996;62(3):167-170. 58. Kawamura YJ, Kuwahara Y, Mizokami K, et al. Patient’s appetite is a good indicator for postoperative feeding: a proposal for individualized postoperative feeding after surgery for colon cancer. Int J Colorectal Dis. Oct 7 2009. 59. Yeung SE, Fenton TR. Colorectal surgery patients prefer simple solid foods to clear fluids as the first postoperative meal. Dis Colon Rectum. Sep 2009;52(9):1616-1623. Now you can read Practical Gastroenterology on the Web. Visit our new web site at www.practicalgastro.com to read the latest issues and our archives! Register and Practical Gastro is at your fingertips! Fellows’ Corner is open to Trainees and Residents ONLY. Section Editor: C. S. Pichumoni, M.D. Read Current Series Articles Send in a brief c
charged on clear liquids on POD 4 if there were no complications. Their diet was advanced at home based on information gathered during post discharge phone calls by a clinician on the research team. There was a trend towards reduced LOS in the study group (aver-age of 4 vs 6 days). Due to the small sample size this was not statistically .
Revenge of the Cyst –Part II NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #55 Joe Krenitsky, MS, RD, Nutrition Support Specialist; Diklar Makola, MD, MPH, PhD, Gastroen-terology Fellow; Carol Rees Parrish MS, RD, Nutrition Support Specialist all at Digestive Health Center of Excellence, University of Virginia Health System, Charlottesville, VA.
Parrish Village News. page 2 Parrish Village News Official publication of the Parrish Civic Association, a non profit coporation. P. O. Box 257 Parrish, FL 34219
WEST COAST HOTEL CO. v. PARRISH. 379 Syllabus. WEST COAST ttOTEL CO. v. PARRISH ET AL. APPEAL FROM THE SUPREME COURT OF WASHINGTON. No. 293. Argued December 16, 17, 1936.-Decided March 29, 1937. 1. Deprivatio
WEST COAST HOTEL CO. v. PARRISH. 379 Syllabus. WEST COAST ttOTEL CO. v. PARRISH ET AL. APPEAL FROM THE SUPREME COURT OF WASHINGTON. No. 293. Argued December 16, 17, 1936.-Decided March 29, 1937. 1. Deprivation of liberty to contract is forbidden by the Constitution if without due process of law; but restraint or regulation of this .
REEs and Electronics REEs have been used in electronics and advanced machinery for nearly three-quarters of a century. Demand for REEs in electronics began in earnest in the 1960s with the introduction of the first color television sets, which initially used europium to produce the color images on the screen.15 Since then,
Carol’s mother, Emilia, dies when Carol is just 8 years old. Young Carol takes the Blessed Virgin Mary as his mother. Carol enters a secret seminary in 1942, and is ordained a priest in 1946. Carol Wojtyla is elected Pope in 1978, and takes the name John Paul II. Pope John Paul II travels to more countries and canonizes more saints than
Ø A 3-minute interview with Carol Dweck on The Growth Mindset by Sal Khan of Khan Academy Ø A 10-minute TED talk on Developing a Growth Mindset by Carol Dweck Ø The cover story from the Stanford Alumni Journal presents a nice overview of Carol and her work. “The Effort Effect” Ø A short news article on Carol in the UK’s SchoolsWeek
A Sesame Street Christmas Carol (2010; with Kristin Chenoweth and Tim Curry; in Children’s) Doctor Who: A Christmas Carol (2011; BBC science fiction) The Smurfs: A Christmas Carol (2011; animated; part of The Smurfs Collection, in Children’s) A Christmas Carol (2012; scary Pop T
